Anticoagulation with Edoxaban in Patients with Atrial High-Rate Episodes
Authors: Paulus Kirchhof, Tobias Toennis, Andreas Goette, A. John Camm, Hans Christoph Diener, Nina Becher, Emanuele Bertaglia, Carina Blomstrom Lundqvist, Martin Borlich, Axel Brandes, Nuno Cabanelas, Melanie Calvert, Gregory Chlouverakis, Gheorghe-Andrei Dan, Joris R. de Groot, Wolfgang Dichtl, Borys Kravchuk, Andrzej Lubiński, Eloi Marijon, Béla Merkely, Lluís Mont, Ann-Kathrin Ozga, Kim Rajappan, Andrea Sarkozy, Daniel Scherr, Rafał Sznajder, Vasil Velchev, Dan Wichterle, Susanne Sehner, Emmanuel Simantirakis, Gregory Y.H. Lip, Panos Vardas, Ulrich Schotten, Antonia Zapf
Journal: New England Journal of Medicine (2023)

Device-detected atrial high-rate episodes (AHREs) are atrial arrhythmias detected by implanted cardiac devices. AHREs resemble atrial fibrillation but are rare and brief. Whether the occurrence of AHREs in patients without atrial fibrillation (as documented on a conventional electrocardiogram [ECG]) justifies the initiation of anticoagulants is not known. Download a PDF of the Research Summary. We conducted an event-driven, double-blind, double-dummy, randomized trial involving patients 65 years of age or older who had AHREs lasting for at least 6 minutes and who had at least one additional risk factor for stroke. Patients were randomly assigned in a 1:1 ratio to receive edoxaban or placebo. The primary efficacy outcome was a composite of cardiovascular death, stroke, or systemic embolism, evaluated in a time-to-event analysis. The safety outcome was a composite of death from any cause or major bleeding. The analysis population consisted of 2536 patients (1270 in the edoxaban group and 1266 in the placebo group). The mean age was 78 years, 37.4% were women, and the median duration of AHREs was 2.8 hours. The trial was terminated early, at a median follow-up of 21 months, on the basis of safety concerns and the results of an independent, informal assessment of futility for the efficacy of edoxaban; at termination, the planned enrollment had been completed. A primary efficacy outcome event occurred in 83 patients (3.2% per patient-year) in the edoxaban group and in 101 patients (4.0% per patient-year) in the placebo group (hazard ratio, 0.81; 95% confidence interval [CI], 0.60 to 1.08; P=0.15). The incidence of stroke was approximately 1% per patient-year in both groups. A safety outcome event occurred in 149 patients (5.9% per patient-year) in the edoxaban group and in 114 patients (4.5% per patient-year) in the placebo group (hazard ratio, 1.31; 95% CI, 1.02 to 1.67; P=0.03). ECG-diagnosed atrial fibrillation developed in 462 of 2536 patients (18.2% total, 8.7% per patient-year). Among patients with AHREs detected by implantable devices, anticoagulation with edoxaban did not significantly reduce the incidence of a composite of cardiovascular death, stroke, or systemic embolism as compared with placebo, but it led to a higher incidence of a composite of death or major bleeding. The incidence of stroke was low in both groups. (Funded by the German Center for Cardiovascular Research and others; NOAH-AFNET 6 ClinicalTrials.gov number, NCT02618577; ISRCTN number, ISRCTN17309850.) QUICK TAKE VIDEO SUMMARYEdoxaban for Atrial High-Rate Episodes 02:17